# Anaphylaxis: Epinephrine or Benadryl first? **URL:** \ **Category:** In My Humble Opinion\ **Created:** [January 4, 2017, 3:09am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291 "2017-01-04T03:09:29Z")\ **Posts on this page:** 17\ **Page:** 2
**Author:** ![dropzone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dropzone/32/7515_2.png) [@dropzone](https://boards.straightdope.com/u/dropzone)\ **Post date:** [January 4, 2017, 11:38pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/21 "2017-01-04T23:38:23Z")
> [@Mama\_Zappa](#): > > Dropzone - scary stuff; I’m glad they stabilized her quickly. Any idea what DID cause the reaction? was it a different antibiotic? different batch of same antibiotic? (as in, one batch was bad). Nobody is interested in digging deeper, for obvious reasons. It’s name is on her chart and in my phone. > [@](#): > > And, can you get the doctors to talk to YOU, since it sounds like you’re getting garbled third-hand info from your wife? Garbled info would be better than none. She’s excessively fond of her pivacy. > [@](#): > > I’d have thought that unless she requires ongoing IV antibiotics, she’d be stable enough to come home unless something else has been going on. Something else is going on–that broken foot. The bits and pieces are all pointed in the right direction, so they probably won’t cut, but she cannot put any weight on it, ruling out a walking cast. Then there’s her high blood sugar > [@](#): > > Also on the sulfites, for my own edification: I’ve reacted to sulfites to foods, but have taken Tylenol 3 tablets with no problem. Do you have any clue whether sulfites in IV meds cause issues? Has your wife reacted to that? I always inform doctors, but when I was in labor with my son and begging for pain relief the first thing they tried to give me was sulfite-preserved. NDFH\* tried arguing with me: “What will it do to you?” “I’m not sure and I don’t thing NOW is the time to find out!” (one of many reasons I regret only hitting her once\*\*) No sulfites in Tylenol 3. If you are allergic to them when taken with food, mainlining them is contraindicated. Kill you dead. > [@Qadgop\_the\_Mercotan](#): > > Just to echo what other experts have said: Benadryl IV if they’re trying to die from an anaphylactic reaction, epinephrine if they’re actually seeming to be succeeding at it. She was succeeding. She could barely gasp, “Help me! I’m dying!” > [@Dr\_Paprika](#): > > I know Dropzone to be very intelligent but unless the patient recovered very quickly after getting epinephrine the situation may be more complex. As I said, you’d have to see it. Not intelligent. Observant. Once she was properly medicated she recovered in minutes. And the nurse giving her CPR was majorly hot, though her facial expression was more vacuous than vivacious. I’m going to Hell. > [@Telemark](#): > > Actually, in a wilderness setting the rule I’ve been taught is push Benedryl ASAP as long as the person can swallow pills (or use liquid Benedryl). She, ex-Medical, claims that childrens chewable Benadryl absorbs faster than liquid, even, and is much more portable. She treated my bee sting with it and a bottle of ammonia passed under my nose like smelling salts (cheaper than an epi-pen and OTC). I stopped fainting/dying (we disagree about where one ends and the other begins), but I also had to stop observing the process of dying, which was disappointing. ---
**Author:** ![Wolf333](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wolf333/32/3460_2.png) [@Wolf333](https://boards.straightdope.com/u/Wolf333)\ **Post date:** [January 4, 2017, 11:46pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/22 "2017-01-04T23:46:46Z")
> [@Mama\_Zappa](#): > > Let’s see if I understand it: > > Benadryl (dipenhydramine) is used to stop the body’s response to the allergen, thereby allowing the downstream symptoms to stop developing / worsening. > > \*\*Epinephrine is used to hit the pause button on the symptoms that are _already_ happening. It doesn’t actually reverse the process (or not much - I guess it brings up BP and heart rate), just puts it on hold. \*\* > > So if you use epi, you have to be doing something else (Benadryl, steroids, whatever) otherwise it just means you’ll die in 15 minutes instead of right now. > > Have I got that even remotely right? Bolding mine The one time that I’ve used my Epi, it was more like a reset than a pause. Everything went back to normal for about 20 minutes, which was long enough to make it to the hospital. The symptoms started up again just I finished checking in. That’s when they gave me the Benadryl. ---
**Author:** ![Patx2](https://avatars.discourse-cdn.com/v4/letter/p/73ab20/32.png) [@Patx2](https://boards.straightdope.com/u/Patx2)\ **Post date:** [January 4, 2017, 11:51pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/23 "2017-01-04T23:51:20Z")
I hope everything is ok with your wife. I have no knowledge of what the proper protocol is, but I know at school, the first response if a child has known allergies and goes into shock is the epi pen. ---
**Author:** ![Renee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/renee/32/287_2.png) [@Renee](https://boards.straightdope.com/u/Renee)\ **Post date:** [January 5, 2017, 12:24am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/24 "2017-01-05T00:24:02Z")
> [@Wolf333](#): > > Bolding mine > The one time that I’ve used my Epi, it was more like a reset than a pause. Everything went back to normal for about 20 minutes, which was long enough to make it to the hospital. The symptoms started up again just I finished checking in. That’s when they gave me the Benadryl. So, would it have been good for Wolf333 to take some benadryl along with the epi at home? And if you don’t have an epi, but someone is having a severe reaction, would crushing the pills before swallowing them help get them into the system faster? And should you give a higher dose of benadryl? (I understand the LD 50 of benadryl is pretty lenient, or is that wrong?) I’m just sort of filing this discussion away for future reference. 🙂 ---
**Author:** ![dropzone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dropzone/32/7515_2.png) [@dropzone](https://boards.straightdope.com/u/dropzone)\ **Post date:** [January 5, 2017, 12:40am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/25 "2017-01-05T00:40:14Z")
Just chew the kid pills. They’re cherry! ---
**Author:** ![Wolf333](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wolf333/32/3460_2.png) [@Wolf333](https://boards.straightdope.com/u/Wolf333)\ **Post date:** [January 5, 2017, 1:39am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/26 "2017-01-05T01:39:30Z")
> [@Renee](#): > > So, would it have been good for Wolf333 to take some benadryl along with the epi at home? And if you don’t have an epi, but someone is having a severe reaction, would crushing the pills before swallowing them help get them into the system faster? And should you give a higher dose of benadryl? (I understand the LD 50 of benadryl is pretty lenient, or is that wrong?) > > I’m just sort of filing this discussion away for future reference. 🙂 My case is different than most in that: 1. I don’t have any allergies. I produce too many mast cells. Because of this, I already take three different antihistamines (Zantac, Zyrtec and doxepin). 2. I have had adverse reactions to Benadryl on at least one occasion (tachycardia), so I prefer to take it under medical supervision. ---
**Author:** ![Telemark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/telemark/32/372_2.png) [@Telemark](https://boards.straightdope.com/u/Telemark)\ **Post date:** [January 5, 2017, 1:49am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/27 "2017-01-05T01:49:29Z")
> [@dropzone](#): > > Just chew the kid pills. They’re cherry! Or use [liquid Benadryl](http://www.benadryl.ca/adult-allergy-medicine/benadryl-liquid-elixir) which is easiest to get into your system. ---
**Author:** ![Chronos](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/chronos/32/134_2.png) [@Chronos](https://boards.straightdope.com/u/Chronos)\ **Post date:** [January 5, 2017, 1:57am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/28 "2017-01-05T01:57:17Z")
I was taught in First Aid training that the rule of thumb is benadryl for milder cases, epinephrine for more severe ones. But the real rule is that any one of our kids with an anaphylactic allergy will bring in meds, as well as paperwork that gives the proper protocol for that specific person (which we have to read over and sign when the kid shows up). Protocols I’ve seen have included just bena, just epi, bena then monitor and epi if needed, bena for mild and epi for serious, etc. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 5, 2017, 2:08am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/29 "2017-01-05T02:08:45Z")
> [@Dr\_Paprika](#): > > … Benadryl stops mast cell degranulation, so stops mild allergies from getting worse, like you say. Ranitidine (Zantac) is a different class (H2) of antihistamine, and is usually added. … I think you made a slight misstep here. Benadryl’s target is the H1 receptor, which is on smooth muscles and capillaries. It blocks the effect of the histamine that the mast cell _has_ released, not stabilizing the the mast cell preventing its degranulation … that’s things like cromolyn. The other bit of Mama Zappa’s post that deserves comment is the 15 minutes bit. The point of EpiPen “in the wild” is that it controls/reverses/prevents the reaction long enough for the individual to get to the ED without panic, and to be there when the med wears off. Of note EpiPen contains sulfites … ---
**Author:** ![dropzone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dropzone/32/7515_2.png) [@dropzone](https://boards.straightdope.com/u/dropzone)\ **Post date:** [January 5, 2017, 4:00am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/30 "2017-01-05T04:00:11Z")
> [@Telemark](#): > > Or use [liquid Benadryl](http://www.benadryl.ca/adult-allergy-medicine/benadryl-liquid-elixir) which is easiest to get into your system. Wife would disagree, as noted above. And the kid pills are easier to lug around the bush. Thanks for the tip, Doc. Duly noted. There are other preservatives that aren’t liable to kill the patient. Why use sulfites? That’s another product I’m cut off from, like wine, instant mashed potatos, and pepperoncini. A quick way to tell if giardiniera is sulfited is by looking at the cauliflower. If it looks edible it’s probably safe. If it’s the ghastly white of a science experiment, it’s sulfited. ---
**Author:** ![Dr\_Paprika](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr_paprika/32/3042_2.png) [@Dr\_Paprika](https://boards.straightdope.com/u/Dr_Paprika)\ **Post date:** [January 5, 2017, 4:02am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/31 "2017-01-05T04:02:11Z")
DSeid is right about Benadryl and degranulation. Though chewable Benadryl is probably slightly quicker than liquid, both are fine, and epi is still needed for severe reactions. All ambulance crews have epinephrine. If she recovered quickly after getting epi, anaphylaxis is more likely but I’d want to see an ECG, lactate, white count, vitals and glucose level. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [January 5, 2017, 4:25am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/32 "2017-01-05T04:25:43Z")
> [@dropzone](#): > > Thanks for the tip, Doc. Duly noted. There are other preservatives that aren’t liable to kill the patient. Why use sulfites? That’s another product I’m cut off from, like wine, instant mashed potatos, and pepperoncini. A quick way to tell if giardiniera is sulfited is by looking at the cauliflower. If it looks edible it’s probably safe. If it’s the ghastly white of a science experiment, it’s sulfited. Every source I can find says that even those with sulfite allergies should use Epi if it’s needed. I mean, after all, you’re getting Epi with the thing you’re allergic to… ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 5, 2017, 4:20pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/33 "2017-01-05T16:20:12Z")
> [@Dr\_Paprika](#): > > DSeid is right about Benadryl and degranulation. … Actually checking on myself not _quite_ so. Or at least incomplete. Yes in terms of the basic model but your original statement turns out to be right too; there appears to be a [self-amplification mechanism](http://or.nsfc.gov.cn/bitstream/00001903-5/131240/1/1000007334701.pdf) as well (“released histamine then stimulates the adjacent mast cells or give positive feedbacks to further stimulate its host mast cells through H1 receptor.” - see fig. 2) And I missed stating the important histamine receptors on various leukocytes, neurons, heart muscle, and of course the usual H2 antagonist target, gastric parietal cells. It’s part of a freakishly [complex network](http://bentham-open.com/contents/pdf/TOIJ/TOIJ-2-9.pdf) of cellular events and feedbacks both positive and negative, with redundant and interacting messengers and signals. Trying to wade through that last article I have flashbacks of trying to diagram these things out in med school … it is not a pleasant flashback! Stuff like how “leukocyte rolling” is blocked by an H1 antagonist, not by an H2 antagonist, but most potently by both at the same time … [shivers] … 🙂 Regarding sulfite sensitivity - a good review article [here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017440/) and of note to this discussion is this line reinforcing **WhyNot** ’s statement: > [@](#): > > Treatment of anaphylaxis in patients who are sensitive to sulphite also poses a conundrum in that administration of adrenaline is regarded as the primary treatment for anaphylaxis, and yet all commercially available preparations of adrenaline contain metabisulphite (37). However, even in patients with serious sulphite sensitivity, the benefit from adrenaline is considered to outweigh the risk of sulfite exposure associated with use of adrenaline in an emergency (38). It is also “interesting” (those who suffer may read that word as “frustrating”) that the mechanism of sulfite sensitivity is so unclear. It does not seem to _usually_ be an IgE or histamine primary allergic reaction itself, possibly more cholinergic mediated bronchoconstriction or prostaglandin and/or leukotriene mediated. ETA: it is also interesting that the spelling in the same article switches between sulphite and sulfite! ---
**Author:** ![dropzone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dropzone/32/7515_2.png) [@dropzone](https://boards.straightdope.com/u/dropzone)\ **Post date:** [January 6, 2017, 3:20am UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/34 "2017-01-06T03:20:52Z")
I look for the -ite in ingredient lists. The metas are worse, but they all make me sick. And there probably ain’t much in a dose or two. Not like half a jar of giardiniera in vinegar. ---
**Author:** ![Mama\_Zappa](https://avatars.discourse-cdn.com/v4/letter/m/71e660/32.png) [@Mama\_Zappa](https://boards.straightdope.com/u/Mama_Zappa)\ **Post date:** [January 6, 2017, 3:21pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/35 "2017-01-06T15:21:06Z")
> [@dropzone](#): > > … > No sulfites in Tylenol 3. If you are allergic to them when taken with food, mainlining them is contraindicated. Kill you dead. > … Actually, at least some makers of acetominophen with codeine DO use sulfites. [Cite.](https://www.drugs.com/cdi/tylenol-w-codeine.html). Have you ever had a doctor say the “kill you dead” thing? I’ve asked numerous doctors - including my former allergist (who also worked at the FDA) and basically get a shrug and a faint “I dunno” from them. One said that the mechanism was _thought_ to be related to the compounds becoming airborne and inhaled but he definitely wasn’t sure of it. I avoid 'em on principle under the assumption that “_might_ kill you dead” is an unnecessary risk. ---
**Author:** ![dropzone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dropzone/32/7515_2.png) [@dropzone](https://boards.straightdope.com/u/dropzone)\ **Post date:** [January 6, 2017, 11:49pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/36 "2017-01-06T23:49:34Z")
No, but I know what they do if I ingest them, then projected the effect if sulfites were injected directly into my bloodstream. But it is very much dose-related. ---
**Author:** ![Mama\_Zappa](https://avatars.discourse-cdn.com/v4/letter/m/71e660/32.png) [@Mama\_Zappa](https://boards.straightdope.com/u/Mama_Zappa)\ **Post date:** [January 13, 2017, 10:08pm UTC](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291/37 "2017-01-13T22:08:19Z")
> [@DSeid](#): > > …It is also “interesting” (those who suffer may read that word as “frustrating”) that the mechanism of sulfite sensitivity is so unclear. It does not seem to _usually_ be an IgE or histamine primary allergic reaction itself, possibly more cholinergic mediated bronchoconstriction or prostaglandin and/or leukotriene mediated… It makes absolute sense to me that it’s a different pathway. The handful of times I’ve had a sulfite reaction were stunning in how quickly they developed - as in, one minute I was fine, the next minute, starting to feel tight, and the third minute starting to panic. This was back before inhalers were all that common - 1981 or so was the last time it happened - so of course I had no rescue meds with me. But for me, a “routine” asthma attack has never, EVER developed that quickly, even when precipitated by something as sudden as exposure to very cold air. Nor does a routine attack self-resolve like that - both times I can recall (eating salad at different restaurants), I was fine by the end of the meal. Whatever it is, it’s THOROUGHLY unpleasant\*, and I’m glad sulfiting agents are used much less (banned entirely from restaurants, perhaps?). - translation: fucking TERRIFYING at best [Previous page](https://boards.straightdope.com/t/anaphylaxis-epinephrine-or-benadryl-first/776291.md?page=1)